High-Risk Antepartum Conditions

Introduction to High-Risk Antepartum

• Week 9 covers high-risk antepartum conditions.
• Learning outcomes include describing pregnancy complications, explaining clinical features of complications, and identifying potential antenatal complications.
• Additional learning outcomes include describing nursing assessments for vaginal bleeding, teaching women with antepartum complications, and demonstrating knowledge of preexisting medical conditions in pregnancy.
• A high-risk pregnancy is a condition due to the pregnancy itself or a pre-existing condition, putting the woman and fetus at risk.
• Risk factors include hypertension, hyperemesis gravidarum, hemorrhagic conditions, surgery/trauma during pregnancy, and urinary tract infections.
• Risk assessment should be ongoing throughout pregnancy and the postpartum period.

Hemorrhagic Disorders

• Hemorrhagic disorders in pregnancy are medical emergencies.
• Maternal blood loss decreases oxygen-carrying capacity and affects oxygen delivery to the fetus.
• Risks include increased risk for hypovolemia, anemia, infection, preterm labor, and preterm birth for the mother.
• Fetal risks include blood loss, anemia, hypoxemia, hypoxia, anoxia, and preterm birth.

Early Pregnancy Bleeding

• Early pregnancy bleeding in the first trimester is often due to fetal complications.
• Bleeding in the 2nd to 3rd trimester is generally due to maternal complications.
• Miscarriage (spontaneous abortion) is the loss of pregnancy before 20 weeks and is a common complication.
• Cause is unknown and variable.
• Nursing assessments and interventions should focus on:
  • Vaginal bleeding
  • Cramping or contractions
  • Vital signs and pain level
  • Administering Misoprostol (Cytotec) & Oxytocin (Pitocin)
  • Rh(D) immunoglobulin (RhoGam) if Rh-negative
  • Providing client understanding and psychological support

Cervical Insufficiency

• Cervical insufficiency involves premature dilation of the cervix.
• The cervix dilates without uterine contractions, resulting in pregnancy loss.
• The cause is unknown but may be related to a history of cervical damage or preterm labor.
• Management includes an ultrasound to check cervical length.
• Bed rest is indicated, avoiding heavy lifting, progesterone.
• Surgical options include cervical cerclage.
• Rhogam is administered if the mother is Rh-negative.
• Close monitoring should be done for preterm labor is necessary.

Bleeding During Early Pregnancy: Ectopic Pregnancy

• With ectopic pregnancy, the fertilized ovum implants outside the uterine cavity (90% in fallopian tubes).
• Obstruction or slowing of ovum passage through the tube can cause ectopic pregnancy.
• Risk is increased with a history of pelvic inflammatory disease.
• Hemorrhage due to rupture is a risk for the woman.
• Decreased fertility is related to removal of the fallopian tube or ovary.
• Classic signs of ectopic pregnancy include abdominal pain within 7-8 weeks after the last menses, amenorrhea, and vaginal bleeding.
• Signs include dull, colicky pain, often unilateral, referred shoulder pain, and signs of hemorrhage and shock.

Ectopic Pregnancy Therapeutic Management and Nursing Actions

• Therapeutic management includes lab/diagnostic testing and medication options.
• Lab/diagnostic testing involves a transvaginal ultrasound and serum hCG.
• Drug therapy with methotrexate dissolves fertilized ovum.
• Surgery (salpingectomy) removes fallopian tubes, if ruptured.
• Administer RhoGam if necessary.
• Nursing actions include assessing the appearance and amount of vaginal bleeding.
• Monitor vital signs and fluid replacement.
• Provide pre- and post-operative care.
• Assess maternal psyche and provide referral for pregnancy loss support group.
• Address future fertility and contraception concerns, including higher risk of having fertility issues.

Gestational Trophoblastic Disease (Hydatidiform Mole)

• Gestational Trophoblastic Disease (GTD) involves rapid deterioration of trophoblastic villi in placenta.
• Gestational tissue is present, but pregnancy is not viable.
• Two common types exist:
  • Partial mole, which may have fetal tissue, but the embryo fails to develop past the early stage, and no viable pregnancy results.
  • Complete mole, with no fetal tissue, no embryo, and no amniotic sac.
• Choriocarcinoma is a chorionic malignancy.
• Rapid uterine growth, no fetal heart rate, vaginal bleeding, and blood loss are all included in assessments.
• Symptoms occur before 24 weeks' gestation.
• hCG levels are persistently elevated or increasing past 10-12 weeks.
• Diagnosis is via ultrasound and high hCG levels.
• Therapeutic management includes evacuation of uterine contents (D&C), baseline hCG level, chest x-ray, and pelvic ultrasound.
• Monitor serial hCG levels weekly until return to normal baseline levels, then monitor monthly for 12 months.
• Monitor for signs of anemia.
• A chest x-ray is done every 6 months to detect pulmonary metastasis.
• Stress reliable contraception for 1 year.

Late Pregnancy Bleeding: Placenta Previa

• In placenta previa, bleeding occurs during the 2nd and 3rd trimesters.
• The cause is unknown but involves placenta implantation in lower uterine segment, nearing or over internal cervical os.
• Total/Complete placenta previa causes total obstruction.
• Low-lying involves implantation in the lower uterine segment, near the internal cervical os.
• Ultrasound monitoring is needed.
• Risk factors include previous placenta previa, uterine scarring, advanced maternal age, smoking, multifetal gestation, hypertension, or diabetes.
• Assessment occurs using painless vaginal bleeding with bright red blood in the second or third trimester.
• Cessation is spontaneous, then recurs, usually at 27-32 weeks' gestation.
• Vital signs are initially stable.
• Uterine is relaxed, soft, and non-tender.

Placenta Previa Diagnostic Tests & Therapeutic Management

• Diagnostic and laboratory tests include ultrasound for placenta placement and transvaginal assessment, as well as labs.
• Labs consist of complete blood count (CBC), hemoglobin (Hgb), hematocrit (Hct), blood type and Rh status.
• If fetal cells appear in maternal circulation, a Kleihauer-Betke (KB) test is performed.
• Therapeutic management depends on bleeding, placenta location, gestational age, labor signs, and symptoms.
• Assess vaginal bleeding and contractions
• Leopold's maneuvers and monitor FHR
• Continuous monitoring of maternal vital signs.
• Administer IV fluids and blood products, as prescribed.
• Anticipate order for corticosteroids for early delivery by cesarean section
• Expected management: observation and bedrest

Late Pregnancy Bleeding: Abruptio Placentae

• Abruptio placentae occurs when the placenta separates prematurely from the uterine wall, compromising fetal blood supply.
• Typically occurs after 20 weeks' gestation and usually in the third trimester.
• Separation can be partial or complete.
• It is a significant cause of third trimester bleeding.
• It is associated with high maternal and fetal mortality.
• Risk factors include maternal hypertension, blunt external abdominal trauma (MVA), cocaine use, smoking, multifetal pregnancy, and premature rupture of membranes (PROM).

Abruptio Placentae: Assessment & Management

• Assessment findings include sudden onset, vaginal bleeding that can be dark/observed, and sharp, stabbing pain with possible abdominal firmness.
• contractions with increased uterine tone may be present.
• Fetal distress/absent FHR and signs of hypovolemic shock may be present.
• Nursing management should proceed with the possibility of an emergent delivery.
• Diagnostic and lab test includes, CBC fibrinogen levels, clotting studies, type & cross-match
• Ultrasound and biophysical profiles are also recommended.
• Treatment includes rapid assessment and intervention.
• Tissue perfusion is accomplished by left lateral position, bedrest, oxygen therapy, vital signs monitoring, fundal height monitoring, and continuous fetal monitoring.
• Stabilize and determine severity.
• If there is fetal distress, plan an emergent cesarean section and administer corticosteroids, as prescribed.
• Monitor urinary output and fluid balance.

Late Pregnancy Bleeding: Abruptio Placentae Maternal & Fetal Risk & Placental Abnormalities

• Maternal risks from occurance of abruptio placetnae:
  • Hemorrhagic shock
  • Disseminated intravascular coagulation (DIC)
  • Postpartum hemorrhage
• Fetal and neonate risks with include:
  • Premature birth
  • Hypoxia, anoxia, neurological injury
  • Intrauterine growth restriction
  • Neonatal death
• Cord insertion and placental variations include velamentous insertion.
• Succenturiate lobe placenta is an extra placental lobe that implants on the membrane.

Hypertension in Pregnancy

• Preeclampsia complicates ~5-10% of all pregnancies.
• Hypertensive disorders are the most common medical complications reported.
• Hypertensive disorders can include:
  • Gestational hypertension
  • Preeclampsia and severe preeclampsia
  • Eclampsia
  • Chronic hypertension
  • Preeclampsia superimposed on chronic hypertension

Gestational Hypertension vs Preeclampsia

• Gestational hypertension is diagnosed after 20 weeks with previous normal BP. BP is > 140/90 mmHg, with measurements taken at least 4 hours apart.
• No proteinuria is present.
• Returns to normal within 12 weeks postpartum, usually resolves within the first week.
• Preeclampsia occurs only during pregnancy and disappears after birth.
• High-risk factors include family history, multifetal pregnancy, black race, obesity, diabetes, age before 19 and after 40, and preexisting medical or genetic conditions.

Preeclampsia: Diagnosis & Nursing Interventions

• Preeclampsia is a pregnancy-specific syndrome involving new-onset hypertension and proteinuria after 20 weeks of gestation.
• It involves vasospasm and poor tissue perfusion that can be mild or severe.
• Reduced kidney function is possible, and can also develop postpartum
• Diagnosis: Elevated BP > 140/90 (2 measurements at least 4 hours apart) and >/= 3 g protein (1+) or more in 24-hour urine collection.
• Nursing assessments and interventions:
  • Monitor blood pressures, V/S and more frequent as indicated.
  • Assess fluid balance; monitor I&O and daily weight.
  • Assess visual changes, headache, LOC.
  • Assess for right upper quadrant pain.
  • Assess deep tendon reflexes (DTRs).

Preeclampsia: Monitor & Medication

• Left lateral position-activity restrictions.
• Labs: CBC, Liver enzymes and creatinine, Uric acid, urine for proteinuria
• Administer medication as ordered, typically an Antihypertensive medication
• Assess the fetus with external monitor:
  • Fetal movement counts
  • Nonstress test
  • Biophysical profile, Amniotic fluid index (AFI)

Severe Preeclampsia & Medications

• Severe preeclampsia can develop suddenly and requires immediate intervention.
• BP may be 160mmHg systolic/110mmHg diastolic or greater two times, 4 hours apart.
• Proteinuria is 5 gm in 24 hours or 4+.
• Oliguria: less than 400 ml in 24 hours.
• Signs include visual or cerebral disturbances, possibly ankle clonus.
• Right upper quadrant pain may be present.
• Antihypertensive medications control blood pressure.
• Examples:
  • Hydralazine hydrochloride (vasodilator)
  • Labetalol hydrochloride (beta-blocker)
  • Nifedipine (calcium channel blocker)
• Magnesium sulfate is administered to for CNS depression.
• Dosage is 4-6 gm, administered over 20 minutes, then 1-2 gm/hour, and monitor levels.
• Calcium gluconate is the antidote for magnesium toxicity.
  • Dosages are 5-10 mEq IV over 5-10 minutes

Magnesium Sulfate Nursing & Eclampsia

• Monitor the client, who may feel flushing initially.
• Monitor BP, pulse, respirations, DTR, LOC.
• Monitor urine output for over 30mL output per hour, and fluid restrictions are 100-125/mL/hour.
• Assess the fetal heart rate.
• If assess signs of magnesium toxicity (decreased DTR, urine output, decrease respirations), discontinue and administer antidote.
• Preeclampsia progresses to Eclampsia when seizure activity is present.
• Eclampsia is similar to preeclampsia but more severe.
• It can occur intrapartum or postpartum with no history of previous pathology.
• Stabilize mother once seizures are controlled.
  • Magnesium Sulfate prevents further seizure.
  • Antihypertensive agents

Eclampsia Warning Signs & HELLP Syndrome

• Sever persistent headaches, visual disturbances, epigastric pain, nausea and vomiting and hyperreflexia with clonus are all warning signs.
• Severe preeclampsia can lead to HELLP syndrome.
• HELLP syndrome causes hepatic dysfunction, diagnosed by changes in lab values:
  • Hemolysis (H) is when Increased bilirubin is elevated.
  • Elevated Liver enzymes (EL) includes elevated AST and ALT.
  • Low Platelets (LP) < 100,000/mm.

HELLP Symptoms & Preeclampsia

• Nursing Assessment for HELLP is similar to severe preeclampsia.
• HELLP symptoms include nausea and vomiting, malaise, right upper quadrant/epigastric pain, edema, and gastrointestinal bleeding.
• Anticipate orders for platelets.
• Only cure is delivery and the disease should resolve within 48 hours.
• HELLP syndrome is associated with increased risk for pulmonary edema, acute renal failure, liver hemorrhage or failure, disseminated intravascular coagulation (DIC), placental abruption, and fetal and maternal death.
• Chronic hypertensive disorders include instances when HTN is present before pregnancy.
• Initial diagnosis is during pregnancy and lasts >12 weeks after birth.
• This is difficult to diagnose and associated with adverse outcomes.

Hyperemesis Gravidarum

• Hyperemesis Gravidarum is defined by severe nausea and vomiting past 12 weeks gestation.
• It is more common with obesity, diabetes, multifetal gestation or first pregnancy
• Carries risk for fetal intrauterine growth restriction (IUG, and preterm birth.
  • May be associated with increased HCG and Estrogen levels.
  • Psychosocial concerns
• Assessment: vomiting excessive for prolonged periods, weight loss, dehydration.
• Assess urinalysis ketones and acetones.
• Assess for liver enzymes, CBC, electrolytes.
  • Ultrasound, HCG levels

Hyperemesis Gravidarum: Management

• Management includes IV hydration (LR) and monitored fluid and electrolytes.
• Pyridoxine (Vitamin B12), may be prescribed.
• Monitor I&O, NPO 24 hours, then clear liquids if no N/V.
• Monitor lab values for fluid and electrolyte imbalances.
• DailY weights are important.
• Antiemetic as ordered:ondansetron, metoclopramide are prescribed .
• Advancing a diet that is slow as tolerated, consist of small frequent Meals
• Explore complementary therapies.

Multiple Gestations and Gestational Diabetes Mellitus

• Multiple gestations are pregnancies with two or more fetuses with two types: monozygotic and dizygotic.
• Confirmed by ultrasound, monitoring during labor, operative delivery-cesarean section (common)are all interventions.
• Uterus is larger than expected for estimated date of birth, ultrasound confirms.
• Anemia is a common finding. Nursing management includes Education and perinatal support, Nutrition support.
• Close monitoring during labor with access and a surgical team.
• Monitor the uterus as postpartum to avoid hemorrhage.
• Gestational diabetes mellitus is diagnosed during pregnancy.
  • Monitor glucose intolerance that was not present before.
  • Placental hormones change with resistance to insulin.
  • Assess effects on the fetus.
• Care management includes screening for diabetes around 24 to 28 weeks.
  • Also early pregnancy for existing conditions.

Gestational Diabetes Mellitus: Interventions

• Interventions include hourly glucose monitoring intrapartum.
• Continuous insulin infusions are important.
• Dextrose solutions are usually avoided.
• After birth, most patients return to normal and reassess after 6-12 weeks.
  • Monitor closely for an increased risk of type 2 diabetes.
  • The patient has a High risk for future gestational diabetes in pregnancy.
• Both pregestational and gestational complications pose risks to the mother and fetus.
• High-risk pregnancy requires astute assessment and specialized care to optimize maternal and fetal outcomes.